Provider Demographics
NPI:1689770919
Name:POLUS, KELLY (PAC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:POLUS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3950
Mailing Address - Country:US
Mailing Address - Phone:406-721-1646
Mailing Address - Fax:406-543-9890
Practice Address - Street 1:610 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3950
Practice Address - Country:US
Practice Address - Phone:406-721-1646
Practice Address - Fax:406-543-9890
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4304604Medicaid
MTQ47525Medicare UPIN